Prone positioning of some critically ill patients becomes new standard of care

On hospital intensive care units, patients with acute respiratory distress syndrome (ARDS), an often fatal condition nationwide, have better outcomes when they are positioned in a prone, or face-down position for most of the day, instead of supine, or face up, according to an article authored by two Christiana Care advanced practice clinicians in the winter 2018 edition of the American Association of Critical Care Nurses’ journal Advanced Critical Care.

The new review article, “Acute Respiratory Distress Syndrome and Prone Positioning,” was coauthored by Dannette Mitchell, MSN, APRN, ACNS-BC, CCRN, of the Wilmington Hospital Intensive Care Unit, and Maureen A. Seckel, MSN, APRN, ACNS-BC, CCRN, CCNS, lead critical care clinical nurse specialist and sepsis leader.

The change requires a team approach to integrate the logistically challenging, multifaceted repositioning procedure into clinical practice, the research showed.

“Our guidelines ensure that all team members are involved in the prone-positioning procedure from planning to procedure and recovery,” Mitchell said. “The updated procedures have improved teamwork and efficiency, changing the process from a purely nursing one to one that is interdisciplinary.”

According to Mitchell and Seckel’s research, ARDS is estimated to be responsible for 10 percent of all admissions to intensive care units worldwide and occurs in nearly a quarter of patients undergoing mechanical ventilation.

Although the mortality rate for ARDS remains high, patient outcomes have improved significantly in the last decade, from an estimated hospital mortality of 90 percent to a reported 46 percent, their research showed.

Prone positioning is now considered first-line therapy for patients with severe ARDS, to reduce lung trauma and improve outcomes. Recent studies show that lying face down for up to 16 hours a day can improve oxygenation and decrease mortality.

The article in Advanced Critical Care tells how Christiana Care updated its procedures and guidelines on prone positioning for patients with ARDS and created Prone Positioning Interdisciplinary Guidelines as the new standard of care for all adult critical care units.

Christiana Care initially developed guidelines for prone positioning in 2010; physicians determined when patients required prone positioning and nursing teams developed a plan to implement the move. A team of providers, nurses, respiratory care therapists, physical therapists and other clinicians developed new interdisciplinary guidelines in 2014 and updated them in 2018.

Part of the update was based on clinical practice guidelines on mechanical ventilation in adult patients with ARDS issued in 2017 by the American Thoracic Society, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

The new guidelines, with specific responsibilities for each staff member throughout the process, strongly recommended the use of prone positioning for patients with severe ARDS.

“Pulmonary care continues to advance with improved technology and new techniques,” Seckel said. “A knowledgeable team that uses the latest evidence-based practice is able to provide the best outcomes for patients.”